Chronic Total Coronary Occlusions: New Treatment Options
The 54-year-old female presented with debilitating angina that had increased over the past 12 months. Cardiac catheterization revealed a totally occluded right coronary artery (RCA). A diabetic and poor surgical risk, the patient was presented with the option of percutaneous revascularization utilizing new state-of-the-art technology. The RCA was opened, and patient has resumed her teaching career without pain.
In a time of rapidly expanding interventional therapies, percutaneous treatment for chronic total coronary occlusions remains a rare option in even the most advanced centers. To offer South Jersey physicians and their patients a percutaneous option, the Cooper Heart Institute has recently become the first center in the South Jersey region to provide a new radio frequency guided technology.
Chronic total occlusion (CTO) occurs in approximately 30% of patients with coronary artery disease. CTO is defined as a vessel occluded with atheromatous plaque and old thrombus that is at least 3 months old. In addition, it is most often identified as having an angiographic blood flow of TIMI (thrombolysis in myocardial infarction) grade 0-1 and absence of a distinct continuous lumen. Percutaneous attempts to treat CTO’s have met with generally poor results, due in part to the incidence of vessel perforation. Most clinicians and patients opt for conservative medical management or, in certain scenarios, surgical repair.
“The technology has been available to cross the lesion; the problem was the absence of some sort of guidance to maintain the wire within the main lumen,” says Janah Aji, M.D., director of the Cooper Heart Institute Cardiac Catheterization Laboratory. “To successfully cross a completely occluded lesion, the interventionalist needs to be alerted that he is nearing the vessel wall. This new system provides that warning,” he added.
The Intraluminal Safe-Cross® System uses the optical coherence reflectometry (OCR) guidance system to navigate the occlusion and provide the critical component of distinguishing between the vessel wall and the lesion. The guidewire can emit a radio frequency energy that provides pulsed micro ablation at the distal tip.
“As you are advancing the catheter, the OCR guidance system, which uses a near-infrared light, alerts you with a reflective waveform and an audible sound when you are approaching the arterial wall,” says Dr. Aji. “This allows you to stop and reposition the catheter and continue safely crossing the lesion.”
Decision to Treat Multiple clinical studies, including the Guided Radio Frequency Energy Ablation of Total Occlusions Using the Safe-Cross Radio Frequency Total Occlusion Crossing Registry (GREAT) Trial, have demonstrated the benefits of aggressively treating this population— with the caveat of careful patient selection. The therapeutic benefits of opening total occlusions include:
- Relief of ischemia and anginal symptoms
- Improved ventricular function
- Improved exercise capacity
- Reduction in need for late bypass by 50%
- Patent artery
- Improved event-free survival
Favorable Lesions
“There are significant patient benefits in successfully treating total coronary occlusions,” says Dr. Parrillo. “However, success in these cases is dependent on several critical components. It is a long and complex procedure that requires a skilled interventionalist and the support of an advanced cardiac center like Cooper,” added Dr. Parrillo.
In addition, appropriate patient/lesion selection is also key to a positive outcome. Favorable predictors of success include:
- Occlusion age < 12 weeks
- Lesion length < 15 mm
- Tapered stump leading to occlusion
- Absence of side branches
- A bsence of intracoronary bridging collaterals
The Safe-Cross® System has also been used effectively in totally occluded peripheral vessels.
“The highest procedural success has been demonstrated in patients with short lesion length, and those with an easily visualized proximal and distal vessel,” says cardiologist, Elias Iliadis, M.D., director of the Cooper Peripheral Vascular Interventional Program.
For more information about treatment of total occlusions, to speak with Dr. Aji or Dr. Iliadis, or to refer a patient, please call: (856) 342-2034.